老年和年轻成年肾移植受者的免疫抑制方案使用和结果：国家登记分析。
Immunosuppression Regimen Use and Outcomes in Older and Younger Adult Kidney Transplant Recipients: A National Registry Analysis.
机构信息
Saint Louis University, Saint Louis, MO.
University of Mississippi Medical Center, Jackson, MS.
出版信息
Transplantation. 2021 Aug 1;105(8):1840-1849. doi: 10.1097/TP.0000000000003547.
BACKGROUND
Although the population of older transplant recipients has increased dramatically, there are limited data describing the impact of immunosuppression regimen choice on outcomes in this recipient group.
METHODS
National data for US Medicare-insured adult kidney recipients (N = 67 362; 2005-2016) were examined to determine early immunosuppression regimen and associations with acute rejection, death-censored graft failure, and mortality using multivariable regression analysis in younger (18-64 y) and older (>65 y) adults.
RESULTS
The use of antithymocyte globulin (TMG) or alemtuzumab (ALEM) induction with triple maintenance immunosuppression (reference) was less common in older compared with younger (36.9% versus 47.0%) recipients, as was TMG/ALEM + steroid avoidance (19.2% versus 20.1%) and mammalian target of rapamycin inhibitor (mTORi)-based (6.7% versus 7.7%) treatments. Conversely, older patients were more likely to receive interleukin (IL)-2-receptor antibody (IL2rAb) + triple maintenance (21.1% versus 14.7%), IL2rAb + steroid avoidance (4.1% versus 1.8%), and cyclosporine-based (8.3% versus 6.6%) immunosuppression. Compared with older recipients treated with TMG/ALEM + triple maintenance (reference regimen), those managed with TMG/ALEM + steroid avoidance (adjusted odds ratio [aOR], 0.440.520.61) and IL2rAb + steroid avoidance (aOR, 0.390.550.79) had lower risk of acute rejection. Older patients experienced more death-censored graft failure when managed with Tac + antimetabolite avoidance (adjusted hazard [aHR], 1.411.782.25), mTORi-based (aHR, 1.702.142.71), and cyclosporine-based (aHR, 1.411.782.25) regimens, versus the reference regimen. mTORi-based and cyclosporine-based regimens were associated with increased mortality in both older and younger patients.
CONCLUSIONS
Lower-intensity immunosuppression regimens (eg, steroid-sparing) appear beneficial for older kidney transplant recipients, while mTORi and cyclosporine-based maintenance immunosuppression are associated with higher risk of adverse outcomes.
背景
尽管老年移植受者的人数大幅增加，但有关免疫抑制方案选择对该受者群体的影响的数据有限。
方法
使用多变量回归分析，检查了美国医疗保险覆盖的成年肾脏受者（N=67362；2005-2016 年）的全国数据，以确定年轻（18-64 岁）和老年（>65 岁）成人中早期免疫抑制方案与急性排斥反应、死亡相关移植物衰竭和死亡率之间的关联。
结果
与年轻受者相比，老年受者使用抗胸腺细胞球蛋白（TMG）或阿仑单抗（ALEM）诱导加三联维持免疫抑制（参照）的情况较少（36.9%比 47.0%），TMG/ALEM+类固醇回避（19.2%比 20.1%）和雷帕霉素靶蛋白抑制剂（mTORi）为基础（6.7%比 7.7%）的治疗也较少。相反，老年患者更有可能接受白细胞介素（IL）-2 受体抗体（IL2rAb）+三联维持（21.1%比 14.7%）、IL2rAb+类固醇回避（4.1%比 1.8%）和环孢素为基础（8.3%比 6.6%）的免疫抑制。与接受 TMG/ALEM+三联维持（参照方案）治疗的老年受者相比，接受 TMG/ALEM+类固醇回避（调整比值比[OR]，0.440.520.61）和 IL2rAb+类固醇回避（调整 OR，0.390.550.79）的受者发生急性排斥反应的风险较低。与参照方案相比，老年患者接受 Tac+抗代谢物回避（调整危险比[aHR]，1.411.782.25）、mTORi 为基础（aHR，1.702.142.71）和环孢素为基础（aHR，1.411.782.25）的方案时，死亡相关移植物衰竭的风险更高。mTORi 为基础和环孢素为基础的方案与老年和年轻患者的死亡率增加有关。
结论
较低强度的免疫抑制方案（如类固醇节约方案）似乎对老年肾移植受者有益，而 mTORi 和环孢素为基础的维持免疫抑制与不良结局的风险增加相关。
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